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MRCPsych Part B > Adult Psychiatry 1.2 > Flashcards

Adult Psychiatry 1.2 Flashcards

1
Q

What did Kendell show in his 1996 study?

A

Pregnancy induced hypertension increased the risk of psychosis almost 9 fold

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2
Q

What obstetric events are linked to schizophrenia?

A

Low birth weight, small for gestational age
Perinatal factors e.g. PIH
Hypoxic events e.g. PROM

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3
Q

What is used to measure obstetric complications during childbirth?

A

Lewis-Murray scale

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4
Q

Which study started research into cannabis and schizophrenia?

A

Swedish study in 1960s by Andreassen

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5
Q

What did the Dunedin cohort show re cannabis and schizophrenia?

A

Exposure at 15 to cannabis compared to 26 showed there was an association with psychosis

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6
Q

What did Bauml et al divide psychosocial interventions into?

A

Obligatory
Voluntary

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7
Q

What is basic level competency?

A

Process of empowerment of patients and relatives to understand and accept the illness and cope with it in a successful manner

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8
Q

Examples of voluntary psycho-social interventions

A

Individual behavioural therapy
Communication training
Family therapy

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9
Q

What is the most basic and important part of psychosocial intervention for schizophrenia?

A

Psychoeducation

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10
Q

Who first employed the term psychoeducation?

A

ANderson

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11
Q

What did psychoeducation first consist of?

A

Briefing patient about their illness
Problem solving
Communicatino training
Self-assertiveness training

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12
Q

What does Cochrane review of psychoeducation for schizophrenia show?

A

Reduction in relapse
Improved compliance

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13
Q

Who did studies into high expressed emotion in families of schizophrenia?

A

Brown & Rutter

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14
Q

What did Brown & Rutter show in families with schizophrenia?

A

Patients in families with high expressed emotion were more likely to experience a relapse during the following year despite medication

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15
Q

Impact of family therapy on schizophrenia?

A

Reduces relapse rate from 64% to 24% when there is high expressed emotion

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16
Q

When is family therapy for schizophrenia more effective?

A

If baseline risk of relapse is increased

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17
Q

NNT for family therapy for relapse prevention in schizophrenia?

A

6

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18
Q

Who created the framework for social skills training?

A

Bellack and Mueser

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19
Q

What are the forms of social skills training?

A

Basic Model
Social problem-solving model
Cognitive remediation model

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20
Q

What is the basic model of social skills training?

A

Complex social repertoires are broken down into simpler steps, practiced through role playing and applied in natural settings.

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21
Q

What is the social problem-solving model?

A

Focuses on improving impairments in information processing that are assumed to be the cause of social skills deficits.
Targets things like medication and sx management, self-care.

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22
Q

What is the cognitive remediation model in social skills training?

A

Corrective learning process begins by targeting fundamental cognitive impairments like attention & planning.

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23
Q

What did Birchwood say re CBT for schizophrenia?

A

Target is emotional dysfunction that accompanies psychotic experience and not the sx themselves.

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24
Q

What did Turkington describe re the elements of CBT for psychosis?

A

Therapeutic alliance - validation
Improving medication adherence
Providing alternate explanations to unusual experiences
Decreasing impact of positive sx
Graded reality testing using peripheral questioning and inference chaining

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25
Q

What did a meta-analysis for CBT in psychosis show?

A

34 trials concluded positive beneficial effects for target sx
No effect on hopelessness

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26
Q

Competitive employment rate for those with SMI?

A

<20%

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27
Q

Elements of supported employment?

A

Goal of permanent competitive employment
Minimal screening for employability
Avoidance of preoccupational training
Individualized placement
Time-unlimited support
Consideration of preferences

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28
Q

Unweighted mean of patients in supported employment programs for obtaining competitive employment?

A

65% vs 26% in controls

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29
Q

Relapse rate of psychosis in one year irrespective of treatment

A

27%

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30
Q

Relapse rate of psychosis in one year if not on treatment

A

61%

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31
Q

Relapse rate of psychosis regardless of treatment if patient has 5 or more episodes in one year?

A

48%

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32
Q

Relapse rate of psychosis if no treatment of patient who has had 5 or more episodes in one year?

A

87%

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33
Q

Relapse rate of psychosis in one year regardless of treatment for patients living in stressful environments?

A

62%

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34
Q

Relapse rate of psychosis in one year if receiving antipsychotics and family education?

A

19%

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35
Q

Relapse rate of psychosis in one year if receiving antipsychotics and social skills training?

A

20%

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36
Q

Definition of recovery for schizophrenia

A

GAF>60

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37
Q

Recovery rate of schizophrenia at 15 years

A

37% with schizophrenia
54% with other psychoses

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38
Q

Who did a meta-analysis into schizophrenia and suicide?

A

Palmer et al

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39
Q

Lifetime prevalence of suicide in schizophrenia?

A

5.6%

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40
Q

Self-harm rates in people with schizophrenia

A

38% had at least one episode in 2-12 year follow up period

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41
Q

Median standardised mortality rate for schizophrenia?

A

2.58

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42
Q

Is standardised mortality rate increasing or decreasing for schizophrenia?

A

Increasing

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43
Q

Which subtypes of schizophrenia have the best outcome?

A

Paranoid
Catatonic

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44
Q

Which subtype of schizophrenia has the worst outcome?

A

Hebephrenic

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45
Q

Which study looked into prognosis of schizophrenia?

A

187 schizophrenic patient study from Chestnut Loge over 19 years

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46
Q

What did Chestnut Lodge study show re prognosis of paranoid schizophrenia?

A

Paranoid patients had older age of onset, developed rapidly in people with good functioning, was intermittent during first 5 years and associated with good recovery.

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47
Q

What did Chestnut Lodge study show re prognosis of hebephrenic schizophrenia?

A

Earlier age of onset
Poor premorbid functioning
Continuous illness
Poor long-term prognosis

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48
Q

What did Chestnut Lodge study show re undifferentiated schizophrenia and its prognosis?

A

Poorly distinguished from patients premorbid state
Early hx of behavioural difficulties
Continuous but stable disability

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49
Q

Factors suggestive of good prognosis for schizophrenia

A

Late onset
Obvious precipitating factors
acute onset
Good premorbid adjustment
Affective sx
Married
FHx of affective disorders
Good social support
Positive sx only
Good initial response to Rx

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50
Q

What is the best predictor of a good prognosis of schizophrenia?

A

Good initial response to treatment

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51
Q

Poor prognostic factors for schizophrenia

A

Early onset
No precipitating factors
Insidious onset
Poor premorbid adjustment
Social withdrawal
Single/divorced/widowed
FHx of schizophrenia
Poor social network/High EE families
Negative sx
Poor compliance
Neurological sx
Hx of perinatal trauma
No remissions in 3 years
Many relapses
Hx of violence

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52
Q

Best predictors of poor short-term outcome in acute psychosis

A

Stressful live events
High EE
Non-compliance

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53
Q

Predictors of good medium (2-5 years) outcome in
psychosis?

A

Females
Married
Social contacts outside home
Acute onset

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54
Q

Best predictor of course of schizophrenia?

A

Course of illness n first 2 years

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55
Q

Which antipsychotics show an effect size difference from first generation antipsychotics?

A

Clozapine

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56
Q

What did CATIE and CUtLASS studies show?

A

Second generation drugs are no better than first in terms of efficacy and cost
Olanzapine better than other atypicals for attrition

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57
Q

Who did a meta-analysis into dose comparison of antipsychotics for psychoses?

A

Davis & Chen, 2003

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58
Q

What did Davis & Chen 2002 find re doses for antipsychotics for psychoses?

A

Maximal effective dose of Haloperidol ranges from 3.3-10mg/day
No evidence that higher doses more effective

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59
Q

Best doses for atypical antipsychotics

A

Aripiprazole 10mg/day
Clozapine >400mg/day
Olanzapine 5mg/day
Risperidone 2mg/day

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60
Q

Guidelines for Chlorpromazine dose/day

A

100mg.day

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61
Q

Guidelines for Quetiapine dose/day

A

75mg/day

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62
Q

Guidelines for Ziprasidone dose/day

A

60mg/day

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63
Q

Guidelines for Aripiprazole dose/day

A

7.5mg/day

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64
Q

What did Essock et al. 2007 do with the CATIE study?

A

Used data to find out whether switching or staying with same medication was useful

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65
Q

What did Essock et al 2002 find?

A

People who stayed on same medication did better, particularly for Olanzapine.

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66
Q

Best medication for aggression?

A

Clozapine
Olanzapine
Haloperidol
(in that order)

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67
Q

What are primary negative sx?

A

Sx that are intrinsic to schizophrenia

68
Q

What are secondary negative sx?

A

Sx that occur in association with or are caused by positive sx, affective sx, medication SE, environment, illness-related.

69
Q

What % of schizophrenic patients have primary negative sx?

A

20-30% (clinical)
14-17% (population)

70
Q

First criteria of deficit schizophrenia?

A

At least 2 of 6 of the following present and of clinical severity:
Restricted affect
Diminished emotional range
Poverty of speech
Curing of interest
Diminished sense of purpose
Diminished social drive

71
Q

Second criteria of deficit schizophrenia

A

2 or more of these features present for preceding 12 months and present during periods of clinical stability.

72
Q

Third criteria of deficit schizophrenia

A

2 or more of these enduring features are idiopathic i.e. not secondary to factors other than the disease.

73
Q

Fourth criteria of deficit schizophrenia

A

Patient meets DSM V criteria for schizophrenia.

74
Q

Difference between DSM IV and V re schizophrenia

A

DSM V has no special attribution to bizarre delusions of first-rank auditory hallucinations.

75
Q

Associations with deficit schizophrenia

A

Frontal atrophy
Familial pattern
Summer birth
Increased eye tracking dysfunctions
More tardive dyskinesia
Poor functional outcome
Lower suicide and depression rates

76
Q

Best antipsychotic for negative sx?

A

Amisulpride

77
Q

What augmentation medication can be used for negative sx?

A

D-cycloserine; partial agonist at glycine modulatory site of glutamatergic N-methyl-d-aspartate receptor.
Selegiline

78
Q

Impact of glycine on negative sx?

A

30% reduction

79
Q

Which study looked into suicide prevention in schizophrenia?

A

Intersept study?

80
Q

What did Intersept study show?

A

Suicidal behaviour significantly less in patients treated with clozapine or olanzapine

81
Q

Which antipsychotics lead to improvement in neurocognition?

A

Second generation

82
Q

What was Goldberg et al. 2007’s RCT?

A

Risperidone v Olanzapine in patients with first episode schizophrenia

83
Q

Finding of Goldberg et al. 2007?

A

Effect size for cognitive change in patients exposed to 2nd gen antipsychotic was similar to healthy control group.

84
Q

NICE recommendations for first line Rx of psychosis

A

PO atypical antipsychotic as per patient choice

85
Q

NICE guidelines if good effect with typical PO antipsychotic but SEs

A

Consider PO atypical antipsychotic

86
Q

Which antipsychotic to use if more than one atypical antipsychotic is considered appropriate?

A

Drug with lowest purchase cost should be prescribed

87
Q

Which treatment should be given for psychosis if discussion between patient and clinician is not possible?

A

PO atypical - lower potential risk of EPSEs

88
Q

How long should monotherapy be trialled for schizophrenia?

A

4-6 weeks

89
Q

IPAP recommendation for initial monotherapy for schizophrenia?

A

Amisulpride
Aripiprazole
Olanzaine
Quetiapine
Risperidone
Ziprasidone

90
Q

IPAP recommendation if initial monotherapy fails for schizophrenia?

A

4-6 week trial of second atypical

91
Q

IPAP recommendation if 2nd monotherapy fails for schizophrenia?

A

6 month trial of clozapine up to 900mg.day

92
Q

IPAP recommendation if persistent sx of psychosis despite 6 months of clozapine?

A

Optimize clozapine and/or augment with ECT or adjuvant medication
Alternate strategies

93
Q

What should the clinician consider each time they review antipsychotics for schizophrenia for a patient?

A

Major suicide risk
Metabolic risk - especially with Olanzapine
Severe agitation/violence
Non-compliance
Depression/mood sx
Substance abuse
Prodromal/first episode
Catatonia

94
Q

What does treatment of future episodes of psychosis depend on?

A

Compliance
Therapeutic responde
Side effects
Cause of relapse
Treatment resistant

95
Q

What % of patients with psychosis relapse despite on treatment?

A

20%

96
Q

What % of patients with psychosis relapse if they do not take their medications?

A

60%

97
Q

Risk of relapse if one stops medication for psychosis

A

Five fold increase

98
Q

Duration of maintenance treatment recommended for psychosis

A

1-2 years

99
Q

Duration of maintenance treatment for multiple episodes of psychosis

A

At least 5 years

100
Q

What medications to change to if EPSEs?

A

Atypicals; avoid high doses, especially of Risperidone

101
Q

Which medications to avoid for metabolic syndrome?

A

Clozapine
Olanzapine

102
Q

Best medications to avoid metabolic syndrome?

A

Amisulpride
Aripiprazole

103
Q

Which medications are safe for high prolactin?

A

Aripiprazole
Olanzapine
Quetiapine

104
Q

Which medications to switch to if problems with sedation?

A

Haloperidol
Aripiprazole
Amisulpride

105
Q

Which medications have fewer SE of tardive dyskinesia?

A

Clozapine
Atypicals

106
Q

Better profile for sexual dysfunction re medications?

A

Aripiprazole
Quetiapine

107
Q

Who did a meta-analysis into depot for schizophrenia?

A

Adams et al.

108
Q

What did Adams et al. find re depot use for schizophrenia?

A

Global improvement among patients given depot compared to those on PO and similar rate of SEs

109
Q

Who did a survey of OP with depot for schizophrenia?

A

Pereira & Pinto 1997

110
Q

What did Pereira & Pinto 1997 find re depot and schizophrenia?

A

Patients who were receiving depots prefered to continue on them.
60% of patients converted to depot and said they felt better on it.
Patients felt when on depot they were able to live normal lives and the depot protected them from relapses

111
Q

Characteristic features of Zuclopenthixol depot

A

More effective in aggressive patients
Better at relapse prevention
High EPSE burden

112
Q

Characteristic features of Flupentixol

A

Antidepressant effect

113
Q

Characteristic features of haloperidol depot

A

Useful in prevention of manic relapse
May need 3-6 months to reach steady state

114
Q

Characteristic features of Pipotiazine depot

A

Fewer EPSEs

115
Q

Characteristic features of Fluphenazine depot

A

May induce depressed mood

116
Q

Characteristic features of Risperidone depot

A

Needs aqueous suspension before injection.
Needs to be stored in fridge
Test dose not required

117
Q

Risk of NMS with depot vs PO meds?

A

Same risk

118
Q

Risk of TD for depot vs PO meds>

A

Same

119
Q

Evidence of high dose prescribing for antipsychotics

A

No evidence that high dose prescribing provides sx relief in those who have not responded at lower doses

120
Q

Guidelines for high dose prescribing

A

Consider alternative approaches such as adjuvant therapy, newer antipsychotics such as Clozapine

121
Q

When are risk factors such as metabolic effects more pronounced in high dose prescribing of antipsychotics?

A

> 70 years of age

122
Q

Guidelines of increasing dose for high dose px

A

Increase dose no more than weekly
ECG
Regular physical examination, obs and hydration status

123
Q

Duration guidance for high dose px

A

For 3 months only; no use in continuing after 3 months if no response

124
Q

Who provided evidence of Clozapine for treatment-resistant schizophrenia?

A

Kane et al. 1998
Wahlbeck et al. 1999 - meta-analysis

125
Q

Describe structure of Kane et al. 1998’s study

A

Multicentre clinical where schizophrenia patients failed to respond to 3 meds, underwent a prospective, single-blind trial of high dose haloperidol for 6 weeks.
Patients who didn’t improve on haloperidol where double-blinded and given clozapine or chlorpromazine for 6 weeks.

126
Q

Results of Kane 1998’s study?

A

Out of 268 patients, 30% of clozapine patients responded compared to 4% of chlorpromazine patients.

127
Q

Meltzer’s conclusino of clozapine?

A

30% of clozapine patients would respond in 6 weeks, 20% by 3 months, 10-20% by 6 months.

128
Q

Relationship between clozapine plasma levels and clinical response?

A

None

129
Q

What plasma level of clozapine should be reached before patient can be considered non-respondent to clozapine?

A

350-450ng/ml

130
Q

Who reproduced the methodology of Kane 1998 and what did they find?

A

Conley et al 1998
Olanzapine no better than chlorpromazine in treatment resistance

131
Q

NICE’s definition of treatment resistance of schizophrenia

A

Lac of satisfactory clinical response to sequential use of at least two antipsychotics for 6-8 weeks; at least one must be atypical.

132
Q

What medications have been used to augment clozapine?

A

Risperidone
Fluoxetine
Anticonvulsants
Amisupride - high potency D2 blockade

133
Q

Studies of augmentation of clozapine with lamotrigine?

A

Improvement in positive sx
No effect on negative sx

134
Q

Studies of augmentation of clozapine with risperidone?

A

Low risperidone dosage (4.5mg/day) and long duration of trial is associated with good outcome

135
Q

Non-pharmacological adjuvant to clozapine?

A

Fish omega oil - ethyl-eicoaspentanoate

136
Q

What does CATIE stand for?

A

Clinical Antipsychotic Trials of Intervention Effectiveness

137
Q

What type of study was CATIE?

A

Double-blind pragmatic RCT

138
Q

Patients in CATIE?

A

1493 patients with chronic schizophrenia across 57 sites from 2001-2004

139
Q

Medications used in CATIE?

A

Olanzapine
Quetiapine
Risperidone
Ziprasidone (added later)
Perphanazine

140
Q

How many patients discontinued treatment in 18 months in CATIE?

A

74%

141
Q

Which medication had lowest discontinuation rate in CATIE?

A

Clozapine - 10 months
Olanzapine - 64%

142
Q

Which medication had highest SE burden in CATIE?

A

Olanzapine

143
Q

Which medication caused most anticholinergic sx in CATIE?

A

Quetiapine

144
Q

Which medication caused most EPSes in CATIE?

A

Perphenazine

145
Q

What happened in phase 2 of CATIE?

A

Those who terminated phase 1 due to SEs (444 participants) were tested with Olanzapine, Risperidone, Quetiapine or ZIprasidone.

146
Q

Effectiveness of medications in phase 2 of CATIE?

A

Olanzapine and Risperidone had equal effectiveness and both better than the others

147
Q

Problems with CATIE

A

Perphenazine only used in one randomized phase
Double-blind treatment decreased resemblance to clinical case
Mean doses used is controversal

148
Q

What is CUtLASS?

A

Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study

149
Q

What type of study was CUtLASS?

A

Unblinded randomised control trial comparing first and second generation antipsychotics

150
Q

Primary outcome of CUtLASS?

A

QoL at 1 year

151
Q

Secondary outcome of CUtLASS?

A

Sx measures at 1 year

152
Q

Participants in CUtLASS?

A

1,227 patients with schizophrenia assessed by their clinical team for medication review because of poor response or adverse effects were randomised

153
Q

Second generation drugs used in CUtLASS?

A

Amisulpride
Olanzapine
Quetiapine
Risperidone

154
Q

Rate of follow-up at 1 year in CUtLASS?

A

81%

155
Q

Results of CUtLASS?

A

No advantage of 2nd generation drugs
Those on 1st generation drugs did relatively better
Patients had no clear preference

156
Q

What was the second phase of CUtLASS?

A

Compared clozapine with other 2nd gen antipsychotics in 136 patients

157
Q

Results of 2nd phase of CUtLASS?

A

Significant advantage for clozapine in sx improvement in 1 year
Patients preferred Clozapine

158
Q

Treatment of Delusional Disorders

A

Fluoxetine 80mg/day; effect at 8-12 weeks

159
Q

Who conducted a systematic review into post schizophrenic depression?

A

Levinson

160
Q

What did Levinson find re post schizophrenic depression?

A

Antidepressants are beneficial for patients stable re psychotic sx

161
Q

Which antipsychotics have antisuicidal effects in schizophrenia?

A

Clozapine
Olanzapine

162
Q

Main treatment for schizoaffective disorder

A

Mood stabiliser

163
Q

Which medication is best for depressive type of schizoaffective disorder?

A

Carbamazepine

164
Q

Who did a meta analysis of 10 RCTs into psychotic depression?

A

Wijkstra et al.

165
Q

What did Wijkstra et al. find re medication treatment for psychotic depression?

A

Combination of antidepressant and antipsychotic is no better than antidepressant monotherapy.

166
Q

Which combination is superior for psychotic depression compared to monotherapy?

A

Antidepressant + antipsychotic compared to antipsychotic alone

167
Q

What do NICE guidelines recommend re treatment for psychotic depression?

A

Combination strategy

MRCPsych Part B (64 decks)

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